Individual
JACKSON PEMBERTON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1 MEDICAL VILLAGE DR, EDGEWOOD, KY 41017-3403
(859) 301-2018
(859) 301-2073
Mailing address
PO BOX 636324, CINCINNATI, OH 45263-6324
(859) 301-2018
(859) 301-2073
Taxonomy
Speciality
Code
Description
License number
State
207ZP0101X
Anatomic Pathology Physician
25835
KY
207ZP0102X
Anatomic Pathology & Clinical Pathology Physician
Primary
25835
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2463507
—
OH
05
—
64258353
—
KY
Enumeration date
09/23/2005
Last updated
09/20/2018
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